ANATOMY OF THE HEART

External sulci
Internal partitions divide the heart into four chambers and produce surface or external
grooves referred to as sulci.
The coronary sulcus circles the heart, separating the atria from the ventricles. As
it circles the heart, it contains:
-

the right coronary artery

the small cardiac vein,
the coronary sinus, and
the circumflex branch of the left coronary artery.

The anterior and posterior interventricular sulci separate the two ventricles. These
sulci are continuous inferiorly, just to the right of the apex of the heart.
the anterior interventricular sulcus is on the anterior surface of the heart and contains:
- the anterior interventricular artery and
- the great cardiac vein,
the posterior interventricular sulcus is on the diaphragmatic surface of the heart and
contains:
- the posterior interventricular artery and
- the middle cardiac vein.
Cardiac chambers
The heart functionally consists of two pumps separated by a partition. (Pump: atrium and
ventricle separated by valve.)
The right pump: receives deoxygenated blood 4m body sends it to lungs.
The left pump: receives oxygenated blood from lungs sends it to the body.
Atria: thin walled & receive blood coming into heart
Ventricles: thick-walled & pump blood out of the heart.
(Muscular wall of left ventricle is thicker as more force is required to pump blood
throughout the body)
Septa: separating the 4 chambers Interatrial, interventricular, and atrioventricular
Blood returns to the right atrium through:
the superior and inferior venae cavae, which deliver blood to the heart from body
the coronary sinus, which returns blood from the walls of the heart itself.

Right atrioventricular orifice: opening in the right atrium through which blood
passes into right ventricle. This is closed during ventricular contraction by the
tricuspid valve.
The interior of the right atrium is divided into spaces indicated by:
The sulcus terminalis cordis: vertical groove that indicates the separation externally
Crista terminalis: indicates the separation internally. It is a smooth, muscular ridge that
begins just in front of the opening of the superior vena cava. It divides the right atrium
into:
Sinus of venae cavae:

This space is posterior to the crista

Derived embryologically from the right horn of the sinus venosus.
Significance: both venae cavae empty into this space.

Atrium proper: The space anterior to the crista, including the right auricle.
Musculi pectinati (pectinate muscles): Ridges on the walls of right atrium and auricle,
which fan out from the crista like the "teeth of a comb."
Right auricle: ear-like, muscular pouch that externally overlaps the ascending aorta.
Opening of coronary sinus: opens medially to the opening of inferior vena cava. It
receives blood from most of the cardiac veins.
Valve of coronary sinus and Valve of inferior vena cava:

Small folds of tissue covering the openings of vena cava n coronary sinus.
Derived from the valve of the embryonic sinus venosus.
During development, the valve of inferior vena cava helps direct incoming
oxygenated blood through the foramen ovale into the left atrium.

Fossa ovalis (oval fossa):

A depression in the septum just above the opening of inf. vena cava.
It marks the location of embryonic foramen ovale.
It has a prominent margin, the limbus fossa ovalis (border of oval fossa).

The foramen ovale: During development, it allows oxygenated blood entering right
atrium through inferior vena cava to pass directly to the left atrium and so bypass the
lungs, which are nonfunctional before birth.

Foramina of the venae cordis minimae or The openings of the smallest cardiac veins:

These are numerous small openings scattered along the walls of right atrium.
These openings are of small veins which drain the myocardium directly into
the right atrium.

Right ventricle: Forms most of anterior surface of the heart.

Conus arteriosus (infundibulum):

The outflow tract (area) of the right ventricle leading to the pulmonary trunk
It has smooth walls and derives from the embryonic bulbus cordis.

Trabeculae carneae:

They are the numerous muscular, irregular structures present on the walls of
inflow portion of right ventricle.
They prevent the suction that could occur in case of a flat surface impairing
the pumping ability of the heart.

Papillary muscles: A few trabeculae carneae having only one end attached to the
ventricular surface & other end to chordae tendineae.
Chordae tendineae: Tendon-like fibrous cords which connect the papillary muscles to
the free edges of the cusps of tricuspid valve.
The three papillary muscles in the right atrium are:

the anterior papillary muscle: largest, most constant, arising from anterior wall
of the ventricle.
the posterior papillary muscle: consisting of 1, 2 or 3 structures, with some
chordae tendineae arising directly from the ventricular wall;
the septal papillary muscle: inconsistent i.e either small or absent, with chordae
tendineae emerging directly from the septal wall.

The septomarginal trabecula (moderator band):

Single specialized trabeculum, forming a bridge between the lower portion of
interventricular septum and base of the anterior papillary muscle.
Significance: The septomarginal trabecula carries the right bundle of the
atrioventricular bundle to the anterior wall of right ventricle.
Tricuspid valve (right atrioventricular valve):
Closes the right atrioventricular orifice during ventricular contraction.

Consists of three cusps or leaflets: the anterior, septal, and posterior

Fibrous ring: Surrounds the atrioventricular orifice and holds the base of each cusp
maintaining the shape of the opening.
Commissures: These are sites at the bases of the cusps, where the cusps are continuous
with each other.
Chordae tendineae arising from the tip of papillary muscles attach to the free
margin of each cusp This helps prevent separation of the cusps (i.e keeps them
closed) during ventricular contraction.
During filling of the right ventricle, the three cusps project into it. When the ventricular
musculature contracts, the valve cusps are forced upward with the flow of blood.
The contraction of the papillary muscles: attached to the cusps by chordae tendineae
prevent the cusps from being everted into the right atrium.
Pulmonary valve:
It closes the opening of the pulmonary trunk.
It is present at the apex of the infundibulum (conus arteriosus), which is the
outflow tract of right ventricle.
It consists of three semilunar cusps with free edges projecting upward into the
lumen of the pulmonary trunk.
Nodule of the semilunar cusp: Middle, thickened portion of the superior edge of each
cusp
Lunula of the semilunar cusp: the thin lateral portions of the superior edge.
The cusps are named the left, right, and anterior semilunar cusps, relative to their fetal
position before rotation of the outflow tracks from the ventricles is complete.
Pulmonary sinuses:
Each cusp forms a pocket-like sinus in the wall of the pulmonary trunk.
After ventricular contraction, the recoil of blood fills these pulmonary sinuses
and forces the cusps closed preventing blood from refilling the right ventricle.
Left Atrium:
The left atrium forms most of the base/posterior surface of the heart. It is derived
embryologically from two structures:
The posterior half, or inflow portion: receives the four pulmonary veins. It
derives from the proximal parts of the pulmonary veins that are incorporated into
the left atrium during development.
The anterior half including left auricle: It contains musculi pectinati and
derives from the embryonic primitive atrium.

Unlike the crista terminalis in the right atrium, no distinct structure separates the
two components of the left atrium.

Valve of the foramen ovale:

It is the depression in the interatrial septum opposite to the floor of fossa ovalis in
the right atrium,
Prevents blood from passing from left atrium to right atrium during development.
This valve may not be completely fused in some adults, leaving a "probe
patent" passage between the right and left atrium.

Left ventricle:
The left ventricle is longer, has thickest layer of myocardium and forms the apex of the
heart.
Aortic vestibule:
It is the outflow tract of left ventricle.
It is posterior to the infundibulum of the right ventricle
Derived from the embryonic bulbus cordis.

Trabeculae carneae in left ventricle: fine and delicate in contrast to those in right
ventricle.
Papillary muscles: Anterior and posterior papillary muscles together with chordae
tendinae are found in the left ventricle.
The interventricular septum has two parts:
a muscular part, (thick & forms major part of septum)
a membranous part. (thin & forms upper part of septum)
Atrioventricular part: is a third part of septum, so called bcoz of its position above the
tricuspid valve, locating it between the left ventricle and right atrium.

Mitral Valve (left atrioventricular valve or the bicuspid valve)

Closes the left atrioventricular orifice during ventricular contraction.

It has two cusps: anterior and posterior cusps.

Fibrous ring surrounds the atrioventricular orifice and holds the bases of the cusps and
the cusps are continuous with each other at the commissures. The coordinated action of
the papillary muscles and chordae tendineae is as described for the right ventricle.

Aortic valve: Closes the opening of the left ventricle into the aorta (similar in structure to
pulmonary valve.) It consists of three semilunar cusps with the free edge of each
projecting upward into the lumen of the ascending aorta.
Aortic sinuses:

They are pocket-like sinuses present in between the semilunar cusps and the wall
of the aorta.
They are -the right, left, and posterior aortic sinuses.
Right and left aortic sinuses: The right and left coronary arteries originate from
them.
Noncoronary sinus and cusp: is the posterior aortic sinus and cusp with no
arteries originating from it.

During the function of aortic valve, as blood recoils after ventricular contraction and fills
the aortic sinuses, it is automatically forced into the coronary arteries.
The Cardiac Skeleton

The cardiac skeleton is a collection of dense, fibrous connective tissue in the form
of four rings with interconnecting areas in a plane between the atria and the
ventricles.
Anulus fibrosus: The four rings of the cardiac skeleton surrounding the two
atrioventricular orifices, the aortic orifice and opening of pulmonary trunk.

The interconnecting areas include thickened connective tissue called:

the right fibrous trigone: between aortic ring and right atrioventricular ring; and
the left fibrous trigone: between aortic ring and the left atrioventricular ring.

Significance of cardiac skeleton:

It helps maintain the integrity (uprightness) of the openings it surrounds

Provides points of attachment for the cusps
Separates the atrial musculature from the ventricular musculature:
-

Atrial myocardium: originates from the upper border of the rings

Ventricular myocardium: originates from the lower border of the rings.

Serves as a dense connective tissue partition that electrically isolates the atria
from the ventricles. The atrioventricular bundle, which passes through the
anulus, is the single connection between these two groups of myocardium.

Coronary Vasculature
Coronary arteries: arising from the aortic sinuses supply the muscle and other tissues of
the heart. They circle the heart in the coronary sulcus.
Cardiac veins:
They empty into the coronary sinus which is located in the coronary sulcus on the
posterior surface of the heart between the left atrium & ventricle.
The coronary sinus empties into the right atrium through the opening of coronary sinus.
Coronary Arteries
The right coronary artery:
It originates from the right aortic sinus & passes down vertically in the coronary sulcus
between the right atrium and ventricle.
During this course, several branches arise from the main stem of the vessel:
atrial branch: passes in the groove between the right auricle and aorta, and gives
off the sinu-atrial nodal branch, which passes posteriorly around the superior
vena cava to supply the sinu-atrial node;
right marginal branch: is given off as the right coronary artery approaches the
inferior margin of the heart and continues along this border toward the apex of the
heart
as it continues on the base of the heart, it supplies a small branch to the
atrioventricular node & gives it final major branch, the posterior
interventricular branch, which lies in the posterior interventricular sulcus.
The right coronary artery supplies:

the right atrium and right ventricle

the sinu-atrial and atrioventricular nodes,
the interatrial septum and a portion of the left atrium,
the posteroinferior one-third of the interventricular septum,
and a portion of the posterior part of the left ventricle.

Left Coronary Artery

It originates from the left aortic sinus of ascending aorta. It passes between the
pulmonary trunk and the left auricle before entering the coronary sulcus.
While still posterior to the pulmonary trunk, the artery divides into two terminal
branches, the anterior interventricular and the circumflex.

The anterior interventricular branch (left anterior descending artery-LAD)

descends towards the apex of the heart in the anterior interventricular sulcus.
During its course, one or two large diagonal branches may arise.
The circumflex branch courses towards the left, in the coronary sulcus and onto
the base of the heart. A large branch, the left marginal artery, usually arises from
it.

The left coronary artery supplies:

most of the left atrium and left ventricle, and

most of the interventricular septum, including the atrioventricular bundle and its
branches.

Variations in the distribution patterns of coronary arteries may occur:

In hearts with a right dominant coronary artery, the posterior interventricular

branch arises from the right coronary artery. So, the right coronary artery supplies
a large portion of the posterior wall of the left ventricle and the circumflex branch
of the left coronary artery is relatively small.
In contrast, in hearts with a left dominant coronary artery, the posterior
interventricular branch arises from an enlarged circumflex branch and supplies
most of the posterior wall of the left ventricle.
In most cases, arterial supply to the sinu-atrial and atrioventricular nodes is by the
right coronary artery. However, vessels from the circumflex branch of the left
coronary artery occasionally supply these structures.

[[[ Medical terminologies:

Left coronary artery left main stem vessel.

Its branch, the anterior interventricular artery the left anterior descending
artery (LAD)
the posterior interventricular artery (the branch of the right coronary artery)
the posterior descending artery (PDA).]]]

CARDIAC VEINS
The coronary sinus receives four major tributaries: the great, middle, small, and
posterior cardiac veins.
Great Cardiac Vein
The great cardiac vein begins at the apex of the heart. It ascends in the anterior
interventricular sulcus (now called anterior interventricular vein), along with
anterior interventricular artery. Reaching the coronary sulcus, the great cardiac vein

turns to the left and continues onto the base of the heart with the circumflex branch of
the left coronary artery. Continuing along its path in the coronary sulcus, the great
cardiac vein gradually enlarges to form the coronary sinus, which enters the right
atrium
Middle Cardiac Vein
The middle cardiac vein (posterior interventricular vein) ascends from the apex of
the heart into the posterior interventricular sulcus towards the coronary sinus along
with the posterior interventricular branch of the right or left coronary artery.
Small Cardiac Vein
The small cardiac vein begins in the lower anterior section of the coronary sulcus
between the right atrium and ventricle. It continues in this groove onto the base of the
heart where it enters the coronary sinus at its atrial end. It is a companion of the right
coronary artery throughout its course and accompanies the right marginal vein along
the acute margin of the heart.
Posterior Cardiac Vein
The posterior cardiac vein lies on the posterior surface of the left ventricle. It either
enters the coronary sinus directly or joins the great cardiac vein.
Other Cardiac Veins
Two additional groups of cardiac veins are also involved in the venous drainage of the
heart.
The anterior veins of right ventricle (anterior cardiac veins) are small veins
that cross the coronary sulcus and enter directly into the right atrium. They drain
the anterior portion of the right ventricle. The right marginal vein may be part of
this group if it does not enter the small cardiac vein.
A group of smallest cardiac veins (venae cordis minimae or veins of Thebesius).
Draining directly into the cardiac chambers, they are: numerous in the right
atrium & ventricle, occasionally in the left atrium, and are rarely associated with
the left ventricle.
Coronary Lymphatics
The lymphatic vessels of the heart follow the coronary arteries and drain mainly into:
brachiocephalic nodes, anterior to the brachiocephalic veins; and
tracheobronchial nodes, at the inferior end of the trachea.

Embryology
The outflow tracts: (the aortic vestibule) of left ventricle and the conus arteriosus
(infundibulum) of the right ventricle is derived from the embryonic bulbus cordis.
The space posterior to the crista - the sinus of venae cavae is derived embryologically
from the right horn of the sinus venosus.
the valve of coronary sinus and the valve of inferior vena cava (derived from the valve
of the embryonic sinus venosus.)
Cardiac conduction system:
The cardiac conduction system initiates and coordinates contraction. The conduction
system consists of nodes and networks of specialized cardiac muscle cells organized into
four basic components:

the sinu-atrial node;

the atrioventricular node;
the atrioventricular bundle with its right and left bundle branches;
the subendocardial plexus of conduction cells (the Purkinje fibers).

The cardiac conduction system establishes a unidirectional pathway of

excitation/contraction which moves from the papillary muscles and apex of the ventricles
to the arterial outflow tracts.
Throughout its course, large branches of the conduction system are insulated from the
surrounding myocardium by connective tissue. This tends to decrease inappropriate
stimulation and contraction of cardiac muscle fibers.
Sinu-atrial node (Cardiac pacemaker)
Impulses begin at the sinu-atrial node. This collection of cells is located at the superior
end of the crista terminalis at the junction of the superior vena cava and right atrium.
The excitation signals generated by the sinu-atrial node spread across the atria, causing
the muscle to contract.
Atrio-ventricular node
Alongside, the wave of excitation in the atria stimulates the atrioventricular node,
which is located near the opening of the coronary sinus, close to the attachment of the
septal cusp of the tricuspid valve.

The atrio-ventricular node is a collection of specialized cells that forms the beginning of
an elaborate system of conducting tissue, the atrioventricular bundle, which extends the
excitatory impulse to all ventricular musculature.
Atrio-ventricular musculature:
The atrioventricular bundle is direct continuation of the atrioventricular node. It splits
into right and left bundles.
The right bundle branch:

continues on right side of the interventricular septum toward the apex of the
right ventricle.
It then enters the septomarginal trabecula to reach the base of the anterior
papillary muscle.
At this point, it divides and is continuous with the subendocardial plexus of
ventricular conduction cells or Purkinje fibers. This network of specialized
cells supplies the ventricular musculature including papillary muscles.

The left bundle branch:

Passes to the left side of the interventricular septum towards the apex.
It gives off branches that become continuous with the subendocardial plexus
of conduction cells (Purkinje fibers).
This network of specialized cells spread the excitation impulses throughout
the left ventricle.

Cardiac innervation
The autonomic division of the peripheral nervous system directly regulates:
heart rate;
force of each contraction; and
cardiac output.
Cardiac plexus: Branches from both the parasympathetic and sympathetic systems form
the cardiac plexus. This plexus consists of:

a superficial part: inferior to the aortic arch and between aorta and pulmonary
trunk and
a deep part: between the aortic arch and the tracheal bifurcation.

From the cardiac plexus, small branches that are mixed nerves containing both
sympathetic and parasympathetic fibers supply the heart. These branches affect nodal
tissue, coronary blood vessels, atrial and ventricular musculature.

Parasympathetic innervation
Stimulation of the parasympathetic system:
decreases heart rate;
reduces force of contraction; and
constricts the coronary arteries.
The preganglionic parasympathetic fibers reach the heart as cardiac branches from the
right and left vagus nerves. They enter the cardiac plexus and synapse in ganglia located
either within the plexus or in the walls of the atria.
Sympathetic innervation
Stimulation of the sympathetic system:
increases heart rate; and
increases the force of contraction.
Sympathetic fibers reach the cardiac plexus through the cardiac nerves from the
sympathetic trunk. Preganglionic sympathetic fibers from the upper 4-5 segments of the
thoracic spinal cord enter and move through the sympathetic trunk. They synapse in
cervical and upper thoracic sympathetic ganglia, and postganglionic fibers proceed as
bilateral branches from the sympathetic trunk to the cardiac plexus.

(TO BE CONTINUED)